Misleading shoulder MRIs lead to unnecessary rotator cuff surgery
Research can be amazing. In the medical journal The archives of bone and joint surgery, a recent study opened with the following statement:
- “Magnetic resonance imaging (MRI) has long been considered a perfect imaging study for evaluation of shoulder pathologies despite occasional discrepancies between MRI reports and arthroscopic findings.”
Did the same thought enter your mind? If it is perfect how can there be discrepancies?
- Before you read on, if you have questions about rotator cuff surgery, get help and information from our Caring Medical staff
Later in the same study when comparing MRI to arthroscopic evaluation, the same researchers noted:
“…an orthopedic surgeon has the advantage of freely changing the patient’s shoulder posture during arthroscopy to detect a lesion in contrast to the single static position of the shoulder in the MRI that is reported by radiologists. This may be another source of disagreement.”(1)
In other words, the MRI is taking a snapshot and not providing the whole picture. However to an experience clinician who has seen many shoulders, an MRI and a look-and-see arthroscopic surgery may be costly, unnecessary and potentially harming to the patients.
Our arguement is that why not try a detailed physical examination by an expereinced Prolotherapists first. No MRI, no surgery, but therapeutic injection.
You are more likely to get an MRI and shoulder surgery if:
Doctors at Brigham and Women’s Hospital and the University of Ottawa studied the prevalence of MRI ordering in cases of shoulder injury. A total of 475 patients who underwent shoulder MRI were included in the study.
The doctors found that:
- patients who had a prior x-ray were more likely to get an MRI.
- patients who got the MRI were more likely to get the surgery
- Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%).(2)
In this research a path was followed:
- If you had an xray you were more likely to get an MRI
- If you had an MRI you were more likely to get a surgery
- If your regular doctor sent you to an MRI you were less likely to get a surgery than if the orthopedist sent you to the MRI
The fault of MRIs
MRIs are frequently used as the basis for determining the need for surgery; however, as with other areas of the body, a shoulder MRI can be very misleading. Some studies have shown that MRIs done on completely asymptomatic individuals show a high prevalence of tears of the rotator cuff. In one study 89 percent of the MRIs on totally asymptomatic shoulders showed abnormalities in the rotator cuff. (3)
In October 2011, the NY Times reported a fascinating article featuring an interview with well know sports surgeon James Andrews, MD. Seeing that most injured athletes and active people receive MRIs when faced with a sports injury, Dr. Andrews set out to see what MRIs showed on people with no pain or symptoms at all. He performed an MRI on 31 perfectly healthy professional baseball players. The results? 90% showed abnormal shoulder cartilage and 87% showed abnormal rotator cuff cartilage despite a 0% incidence of pain!
The article goes on to cite a few other well known orthopedists who explain that MRIs are sensitive but not specific and that abnormalities are usually inconsequential. In fact there are almost never “normal” MRIs. Unfortunately the use of MRIs has become so common that people believe good and accurate care must involve ordering a fancy test. Many of these doctors cited agree that a proper diagnosis can be made by taking a thorough physical and historical evaluation.
An earlier study from 2010 confirmed what many knew: “Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.”4 Clearly the physical examination is the failsafe to errant MRI observation.
The question in the above study is which is better, MRI or arthroscopic exploratory surgery? Both have their benefits. The MRI is not surgery, the arthroscopic is and allows the surgeon to see the shoulder in motion by manipulating the arm during surgery. This is why we use a DMX machine at Caring Medical. The DMX is a motion picture of the bones while a person is moving. It is a dynamic diagnostic tool, versus a static one, and can be used for all joints of the body. The scan is produced in real time, while the person is moving. Read more about the DMX imaging tool.
Treatment options for rotator cuff and shoulder pain are discussed in our articles: Prolotherapy for shoulder pain.
- Rotator Cuff Tear Alternatives To Surgery In this article we discuss the problem of initial rotator cuff tear and re-tears caused by non-healing of the rotator cuff tendons and non-surgical options.
- Rotator Cuff Tendinopathy – Tendinitis – Tendinosis In this article we discusses diagnosis and treatment of Rotator Cuff Tendinopathy. Treatments include conservative care and the emerging science of biological augmentation (Platelet Rich Plasma Therapy and Stem Cell Therapy).
If you have questions about rotator cuff surgery, get help and information from our Caring Medical staff
1. Sefidbakht S, Momenzadeh OR, Dehghani S, Gerami H. MRI-Arthroscopic Correlation in Rotator Cuff Tendon Pathologies; A Comparison between Various Centers. Archives of Bone and Joint Surgery. 2016;4(2):141-144.
2. Small KM, Rybicki FJ, Miller LR, Daniels SD, Higgins LD. MRI Before Radiography for Patients With New Shoulder Conditions. J Am Coll Radiol. 2017 Apr 20. pii: S1546-1440(17)30214-4. doi: 10.1016/j.jacr.2017.02.031.
3. Bencardino JT, Beltran LS. Pain related to rotator cuff abnormalities: MRI findings without clinical significance. J Magn Reson Imaging. 2010 Jun;31(6):1286-99.
4. Farley TE, Neumann CH, Steinbach LS, Petersen SA.The coracoacromial arch: MR evaluation and correlation with rotator cuff pathology.Skeletal Radiol. 1994 Nov;23(8):641-5.